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Coroner’s Cases

Delving through Coroner’s cases may seem intrusive, uncomfortable and voyeuristic.

The reality is that the Coroner often makes recommendations … which may not be translated into practice for some time, wither due to systems issues (not least resource limitations) and lack of awareness. As rural doctors we have a tough remit – practicing the breadth of medicine, often without the backup and resources enjoyed by metropolitan specialists.

I believe that FOAMed can help bolster traditional sources of learning – particularly to “help bring quality care, out there” to rural Australians. Even more so when we recognise that ‘critical illness does not respect geography’ and so despite our resource limitations, we need to be able to at least initiate management for the whole gamut of clinical presentations.

Part of that process requires not just technical skills, but also awareness of non-technical skills and understanding limitations/difficulties inherent in our practice. Relevant Coroner’s findings can help shape our practice and are useful, if lessons learned are translated into tangible application in the bush.

One of my favourite papers is “If Nothing Goes Wrong is Everything Alright?‘ – an examination of statistical and psychological factors around rare events in medicine. If we accept that our work involves some degree of risk, for both doctor and patient, then we need to be able to assess this risk, manage it and ideally to mitigate against it.

But if such events are rare, then they may develop an attitude of ‘why bother? It won’t happen to me!’ amongst individual doctors, nursing staff or hospital admin. Worse, doctors may fall back on anecdote ‘I have never had difficulty with intubation!’ – whilst factually true, may be falsey reassuring when numbers of procedures is low.

The Elaine Bromiley case is one with which most GP-Anaesthetists will be familiar. For me this translated into examining not just my technical competence in airway management, but a long hard look at other factors. From this I have taken it upon myself to develop

  1. a crisis manual for use in the rural OT and ED, with adjuncts like ED prompt cards & an RSI kit dump
  2. use of a difficult airway trolley in my hospital, backed up with signage and protocols
  3. team training in crisis management with ED and OT staff
  4. a survey of rural GP-anaesthetists and their access to difficult airway equipment, presented at RMA2012, SMACC2013 and published in Rural & Remote Health
  5. FOAMed resources like this for sharing between rural doctors

…and that is just on one area of practice!

Here is a selection of Coroner’s Cases relevant to rural doctors.


Ever ordered an investigation? Of course you have! ALWAYS remember that the doctor who ordered the test is responsible for followup – so don;t discharge someone from the ED with a discharge summary saying ‘GP to follow up serum rhubarb’…and don’t send someone in for a scan then fail to act on the radiologist’s recommendations! Read this report and recommendation from the SA Coroner on need to followup, even to get police and ambulance to pay a visit if urgent…


Problems with elective anaesthesia, involving the FastTrach iLMA & oxygenating bougie/catheter

Bottom line – don’t be afraid to awaken your patient and cancel the case. Use caution with iLMAs, they can be fiddly to remove once ETT sited – I have switched to AirQ-II iLMAs on this basis…

Extubation of a patient with known difficult airway (in a different institution)

Extubation is potentially risky – this unfortunate case documents failed attempts to re-intubate a patient, extubated in an ICU on different site from previous (difficult) intubation. Lesson? Always inform colleagues of a difficult intubation – it may be very relevant down the track! Use the UK’s DIfficult Airway Society EXTUBATION GUIDELINES.

An unhappy mix of Obesity, OSA, PCA, BDZs and abnormal post-op obs

Highlights the need for appropriate pre-anaesthetic assessment, caution with obesity, OSA and opiates, as well as problems with assessment post op. Hindsight is 100%…

Failure to recognise displaced endotracheal tube

This can occur anywhere – in this case ICU, but more pertinently for rural doctors, in OT, in ED, or when transferring a ventilated patient. Like NAP4, this case demonstrates the need for mandatory ETCO2 monitoring wherever an airway is managed. Period.

Anaphylaxis at a remote nursing outpost – could you talk through a surgical airway scenario on the phone?

Talking through a procedure is the ultimate test of whether you can do it. This case pertains particularly to difficulties with the growing problem of allergies causing anaphylaxis, the need for familiarity with anaphylaxis guidelines, & the huge challenges faced by remote area nurses and the DMOs who support them. Truly ‘critical illness does not respect geoggraphy’


Problems with psychiatric sedation – causing loss of airway and death

One of the problems of psychiatric sedation is that patients risk loss of airway protective reflexes – I now approach such cases with the same manner as sedation int he ED/OT, mindful that they are unfasted and may have comorbidities, but that an elective pre-anaesthetic check is unfeasible when agitation causes a risk to self or others. ETCo2 monitoring and equipment to manage a difficult airway should be to hand, and a thorough ‘risk assessment’ made. I use a prompt with a psych safe sedation matrix as a helpful guide.

A determined suicide

A young lady makes a deliberate, considered attempt at suicide – successfully. This case raises issues of suicide risk assessment. I now use the TRAAPED SILO SAFE method discussed in ‘Emergency FOAMed’ section

Managing a suicidal patient in a country hospital

A sad case, highlighting that despite thorough risk assessment, a determined patient may inflict self-harm. The need for 1:1 nursing and removal of any potential weapons etc is the standard – whether this is achievable with limited staff is a problem we often face.


Failure to read the GP letter and need for referring doctors to back up with a phone call

SAH is a diagnosis that can be missed, with this case obfuscated by a falsely reassuring scan despite ongoing headaches. It also demonstrated a failure of the receiving hospital to ‘marry’ referring doctor’s letter of referral with the patient in the ED – but perhaps could have been mitigated in some part by a phone call from the GP. Regardless, it demonstrates some of the difficulties in communication between referring and admitting teams – for which we could all do better.

Atypical presentation of SAH

Headaches need thorough workup, especially when ongoing and repeated. History, history and history…

Chest pain and low risk ACS protocols

In South Australia we are now well supported with backup from the Integrated Cardiovascular Clinical Network (iCCNet) providing 24/7 assistance with ECG interpretation and patient disposition for rural doctors. Hopefully other States have the same. Check out their site for protocols etc if not

Four more cardiac deaths in country SA

Emphasises the need for rural doctors to consider prehospital assessments patient risk factors, use of serial ECG and troponins and available back up when evaluating a patient with chest pain.

Delays in the ED

In some areas, getting doctors to attend nursing home patients is difficult – meaning that many depend on busy and overcrowded EDs for same-day care. Hopefully this is one area in which rural doctors can excel – as we are both GP, nursing home deputising service and ED doctor all rolled into one!

A case of missed septic arthritis

Thinking septic arthritis? Then the joint needs to be examined. Period.

An old doctor makes a mistake – anaphylaxis to antibiotic

Failing to ask about allergies can lead to disaster. The Coroner also makes a comment on the dearth of rural doctors in regional Australia and an ageing workforce.

The deteriorating patient

Stoic patients and the inherent difficulties in recognising evolving sepsis, can conspire to cause death. Whether implementation of charts to aid identification of the deteriorating patient will be translated to differences in morbidity and mortality remains to be seen. Sepsis still kills…

Post op sepsis

Leading on from sepsis, delay to definitive surgery for suspected faecal peritonitis can be disastrous. Again medical practitioners may struggle in the face of a risk of sudden acute deterioration in an otherwise stable patient.

D&V in a child with death by hypernatraemc dehydration

Assessement of paediatric patients for dehydration is something we all do – but can be difficult, with skin turgor less useful in hypernatraemic dehydration. Consideration of admission, particularly when parents face a prolonged travel to/from medical review, low threshold for admission and both careful examination and explanation are useful reminders from this unfortunate case.

Kids, coma and coning

A blocked VP shunt is not a case we see often – but needs a high index of suspicion and again highlights the need for access to old notes, in this case old CT scans. Digital radiology may be of assistance in the future.


Subgaleal haemorrhage after Ventouse delivery

Reliance upon haemodynamic measurements alone is falsely reassuring – we know this from other causes of trauma. Similarly when there is bleeding, one needs to ‘find the bleeding, stop the bleeding’ and replace with blood products.

PEA as sign of life in neonate

If a child is born with no pulse but electrical activity detected on ECG, then is this PEA sufficient to decide whether stillbirth vs live birth. The Coroner has made a determination.

Homebirth deaths

The Coroner makes recommendations, particularly regarding home birth of twin and breech babies and need for either midwife or medical practitioner to conduct such births.

Problems with management of PPH in a rural setting

PPH is one of those crises that both obstetrician, anaesthetist and the team around them need to be familiar with. One can make a case for ready availability of checklists, a PPH box and simple effective medication in the rural setting.

Neonatal sepsis & GBS screening

Failure to consider neonatal GBS sepsis in the face of a negative vaginal screening swab highlights some of the problems of screening – as well as the potential of administering unnecessary antibiotics to women who test positive when screened but are free of GBS at delivery. The Coroner calls for a rapid screen intrapartum – a test we do not (yet) have, but which would clearly obviate false positive/negative tests at 37 weeks. Regardless of screening results, PROM needs to be remembered as a risk for neonatal sepsis.

Post-op spinal headache – need for followup and re-evaluation if any concerns

Whilst spinal headache is not infrequent (1% cited here), ongoing headache requires review – and that any discussion needs to be documented, both before procedure and afterwards.

1 Comment

  1. […] reports, it makes for salutary reading and in due course I shall add it to the other list of Coroners cases of relevance for rural doctors, over at […]

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I am a Rural Doctor on Kangaroo Island, South Australia with interests in EM, Anaes & Trauma. I am an Ass/Prof in Aeromedical Retrieval with Charles Darwin University and hold senior specialist (retrieval) positions in NT and QLD Avid user & creator of #FOAMed; EMST & ATLS Director, Instruct & Direct on; faculty for Critically Ill Airway course and smaccAIRWAY workshops. Opinions expressed on these sites must not be used to make decisions about individual health related matters or clinical care as medical details vary from one case to another. Reader is responsible for checking information inc drug doses etc.

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